Clinicians' Stress Levels During Soft Tissue Augmentation Using Autogenous Connective Tissue Grafts: A Pilot Study

OBJECTIVES: To quantify intraoperative stress responses in clinicians performing mucogingival surgery using subepithelial connective tissue grafts (SCTG) for mucosal thickening by combining physiological and psychological measures and to explore the feasibility of stress monitoring in this surgical context. MATERIALS AND METHODS: Eleven clinicians performed 14 SCTG procedures. Physiological stress was assessed using heart rate (HR) and salivary cortisol measured at multiple time points from morning baseline through the evening. Psychological stress and workload were evaluated using validated questionnaires, namely the short-form State-Trait Anxiety Inventory (STAI-6) and the Surgery Task Load Index (SURG-TLX). Data were analyzed with linear mixed-effects models to account for repeated measures in this exploratory pilot study. RESULTS: Heart rate showed a significant overall time effect (p < 0.001), with transient increases during incision, flap preparation and graft harvesting, followed by recovery during suturing. Salivary cortisol levels decreased progressively throughout the day (p < 0.01), consistent with normal diurnal variation and indicating the absence of sustained endocrine stress. Heart rate and cortisol patterns did not differ by clinician experience (< 3 years or ≥ 3 years). STAI-6 scores remained stable over time, whereas SURG-TLX responses identified high mental demand and task complexity as the dominant contributors to perceived workload. CONCLUSIONS: SCTG procedures are associated with short-term physiological stress activation without concomitant increases in perceived anxiety, suggesting an adaptive stress and well-regulated responses among clinicians. CLINICAL SIGNIFICANCE: SCTG causes short-term physical stress, but clinicians appear to cope well and do not feel more anxious while performing them. Characterizing stress dynamics during mucogingival surgery may help inform future research on clinician performance, fatigue, and procedural safety in soft tissue augmentation.